Provider Demographics
NPI:1437127388
Name:VANDERGRIFT, JOHN H (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:VANDERGRIFT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 AMERITECH DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3161
Practice Address - Fax:574-273-1137
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036755207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8460412Medicaid
IN100259060Medicaid
WAG8865303Medicare PIN
223220NMedicare ID - Type Unspecified
IN100259060Medicaid
WA8460412Medicaid
IND95451Medicare UPIN